Choline on the Brain? A Guide to Choline in Chronic Fatigue Syndromehttp://phoenixrising.me/research-2/the-brain-in-chronic-fatigue-syndrome-mecfs/choline-on-the-brain-a-guide-to-choline-in-chronic-fatigue-syndrome-by-cort-johnson-aug-2005
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The Dr. Logan Gut Interview Part II

If you do take probiotics are there any supplements that can help boost probiotics effects?

In recent years so-called prebiotics have been touted for boosting levels of Lactobacillus and Bifidobacteria in the gut. It is quite clear that prebiotics (inulin, chicory root, fructo-olligosaccharides) can increase both Lactobacillus and Bifidobacteria, however it remains unknown if they are also promoting undesirable bacteria as well. There have been hints that they can.

There are now two causes of concern for CFS patients and prebiotics – i. prebiotics have been shown to promote intestinal permeability, irritate the gut lining (this is a massive problem, especially when considering the new studies from Dr Michael Maes who documnented intestinal permeability in CFS) ii. prebiotics can increase the amount of lactate produced in the gut (now that we know there is already excess lactate production and/or inadequate lactate clearance, this is an obvious caveat).

On a personal level your conjecture that fiber induced fermentation in the gut could be associated with increased anxiety and aggression was intriguing since I’ve always felt that ’edginess’ is a key factor in my version of ME/CFS. But how do fiber induced problems in the gut translate into central nervous system problems? A study by Dr. Shungu has suggested increased lactate production in the brain may be occurring in ME/CFS patients; could this have anything to do with lactate production in the gut?

When too much fermentable fiber shows up in the large intestine there is a massive uptick in the production of D-lactate. Since, in CFS, we now know there is already over-production of D-lactate the blanket statements to eat more fiber may not be well suited to CFS. For example, animal studies show that excessive D-lactate production, due to excess fermentable carbohydrates showing up in the distant portion s of the gut, can increase aggressive an anxious behavior. It completely throws them off.

The same phenomenon has been written up numerous times in cases of short bowel syndrome. These are individuals who have had a portion of the small intestine removed, they are more prone to the over-fermentation of fiber-rich carbohydrates in the large intestine and an excess amount of D-lactate is produced. They can experience brain fog, lowered mood state, hypothamic dysfunction and anxiety when transient elevations in D-lactate occur.

Since we know that CFS patients have both bacterial overgrowth and excess D-lactate production (and/or lack of D-lactate clearance) a similar situation may be occurring. Ultimately, excess prebiotics and even excess Lactobacillus strains may worsen the situation in short bowel syndrome, and perhaps CFS as well.

I was very interested in Dr Shungu’s work as well. It certainly suggests that if excess lactate is making it to the brain (and we already know that systemic lactate can cause anxiety in adults with no history of anxiety) it can have multiple implications. Obviously, we have just begun to scratch the surface of this research, however in moving forward we should be very selective of the stains we use for CFS clinical trials.

Your statement that ‘fiber restricted’ diets can be helpful in this disease is a little jarring to hear given all the emphasis these days on high-fiber diets. You also noted that a fiber restricted diet cut the production of hydrogen and methane gas by more than half in one study. What is a restricted fiber diet look like? Are certain types of fiber worse than others?

Yes, while most adults and children in developed nations may need more fiber, those of us with CFS may actually be adding fuel to the fire. An elemental (liquid food) diet has been shown to help eradicate small intestinal bacterial overgrowth and gut excess H2S production. At this point we need more concrete studies although the soluble fiber in oats, barley, rye and root vegetables will be more likely to fuel fermentation and increase lactate production.

You noted that excessive fermentation in the large intestine can lead to the overproduction of lactic acid yet fermented lactic acid producing vegetable products such as sauerkraut, pickles and miso (as well as yogurt) are also sometimes recommended for gut issues. Do you recommend against using those products?

No, generally these would be good choices if not in excess. There is a difference between foods that have been fermented, and foods that are awaiting fermentation by our own bacteria. Still, excessive dairy sugars arriving in the lower gut may be an issue and dairy has been associated with problems in short bowel syndrome with excess D-lactate production.

If someone goes on a fiber-restricted diet how soon should they know if it is working for them?

Within a few weeks

What tests can patients take to assess the status of their small intestine with regards to bacterial overgrowth, hydrogen sulfide gas production, leaky gut and fiber problems?

In addition to Dr K DeM’s exciting new H2S urine test, there is also a test for small intestinal bacterial overgrowth…it is called the lactulose-hydrogen breath test. Similar tests are available for assessment of intestinal permeability. In North America, Genova Diagnostics does the small intestinal bacterial overgrowth and intestinal permeability tests.

There are blood tests for D-lactate; however, by the time a CFS patient sets up the testing the lactate may return to normal. That test is unique in that it is all about timing. Hopefully we will see some clinical investigations in CFS with patients consuming prebiotics and/or decent portions of fermentable carbohydrates and then evaluating both blood and urine lactate in the hours that follow.

A study by Dr. Burnett several years ago suggested that chronic fatigue syndrome patients often suffer from ‘reduced gastric emptying’ it seems to refer to food products remaining in the gastrointestinal system for longer than normal. Would this contribute to fermentation and bacterial overgrowth problems ?

It would certainly contribute to the upper gut symptoms after a meal. It also hints that there are electrical problems on GI tract in general. If there are any problems along the line, it can lead to stasis. We need more work in this area. What may be happening is similar to the folks with short bowel syndrome (although CFS patients may have a structurally intact small intestine, the SIBO may make it a functionally poor portion of the organ) where food material may be passing through the small intestine and then literally get “dumped” into the large intestine. When this happens with fructose, for those who do not absorb fructose well and it speeds through the upper gut, there is massive fermentation and mood related symptoms!

One of the beneficial aspects of enteric-coated peppermint oil is that it helps regulate peristalsis. This is almost certainly why most of the dozen plus trials of ECPO (alone or combined with caraway seed oil) in IBS and functional dyspepsia have shown good results.

Can one to some extent assess one’s bowel health simply by noting the consistency and quality of one’s bowel movements? That is could you say that someone who has one regular well formed bowel movement a day which was not accompanied by gas probably did not have problems with fermentation/hydrogen sulfide gas production?

A regular, well-formed bowel movement will not exclude a potential problem with gut flora alterations. I would be much more inclined to work with the tests available. While these breath test and intestinal permeability tests are imperfect (and the new H2S test requires outside validation), they would tell us much more than bowel movements when it comes to the internal consequences of undesirable bacteria.

I’ve always noticed that abstaining from food is helpful for me for short periods. On the converse many ME/CFS patients experience a considerable letdown 10 minutes or so after they eat. It seems that food does make a difference but this is occurring long before, one would think, food reaches the gut. Do you have any idea what’s going on here?

A period of fasting may be lessening the load of lactate, propionate and H2S…but is not going to be the Rx here. I am not sure about the quick exacerbation of symptoms. I have heard from a number of patients that symptoms are worsened within an hour, and this may be indicative of the small intestinal bacteria having a feast in the upper gut. The ensuing increased intestinal permeability allows unwanted material to pass through the gut wall and fire up the flames of low-grade inflammation.

For more on this topic I would urge visitors to your blog to further investigate the work of Dr Michael Maes and colleagues who have been doing great work in CFS, gut flora and intestinal permeability.

Are there any books you recommend on irritable bowel syndrome or the gastrointestinal system for ME/CFS patients?

I have yet to find one that is specifically suited to the needs and complexities of CFS. The problem is that CFS patients don’t have IBS per se, and the approaches don’t always apply.

The findings in the CFS-GI connection (Drs K DeM, Maes in Europe, Dr Bested in Canada) are so new that a well-rounded gut-specific resource is still some distance away - hopefully soon, but we really need clinical trials to validate specific avenues of approach. As exciting as these gut findings have been, it is important to underscore that we are still on the bridge between hypotheses and true clinical guidance in CFS.

Thanks Cort for your dedication and hard work to the amazing, resilient community of medical underdogs, the CFS patients.

And really hitting it, in my opinion. Speaking just for myself, the eating habits I've developed over the years, thanks to the dastardly Food Pyramid, the low-fat debacle, and my early hippie vegetarian days with no meat and lots of grains and other "healthy" carbs helped set me up for one major chronic hit.

There have been other factors too, but it's good to hear someone talk about the dietary factor -- without bowing to the usual sacred cows of our society.

I understand that what works for one might not work for another. Not everyone needs to live on a caveman diet like I do. But it makes me nuts to listen to so many going on about the absolute goodness of a whole grain diet, low fat, less meat, etc. I worry about the ones who still innocently believe this (like I did) and become ill in large part because of this (like I did).

I cleaned up my diet again, stopped the probiotic soya yogurt and within 7 days I had to stretch my muscles with various yoga poses.

Originally I was doing no processed, low carb, high protein but slipped back to eating ice cream, cake etc as my neuralgia pain subsided. I then started to feel really ill again, glands, aching 'flu crashes. I tried to work out what I was doing differently to 3/4 months ago and the only thing I could think of was my indulgences.

After I read this interview I decided to be even more careful.

Now I wouldn't say I am an axious person but when I started driving again about four months ago just for a mile each day (to pick up daughter from school) and then extra to take her riding once a week (about 10 miles) I noticed I had an 'undercurrent of apprehension'. I thought it was because it was all new again and it would pass as I became more confident. It didn't, and I started having my migraine type crashes more often. I stopped driving because I thought it must be too much for me. That was about six weeks ago.

I'm driving again now and I have no undercurrent, so I presume this is what Dr Logan meant by anxiety and d-lactic acid.

Thanks again Cort it means I'll be able to do more with my daughter during the Summer holidays.
Bx

The gut problems are fascinating and strange... I did a stool test (expensive!) which showed low lacto and bifido bacteria with high strep and prevotella, pretty much inline with what De Meirleir's recent paper indicated.

This was back in '07 and the doc advised VSL#3, the high voltage probiotics. Several months later and after another stool test the lactobacillus had stuck so well I was showing too high...but the bifido was still low. The strep and prevotella were a little less.
Unfortunately I didn't notice anything really in the way of improvements but I am now back on bifido probiotics. My testing seems to at least partly agree with what Dr Logan wrote in Cort's blog, part 1, I think.
I can't take the fructo-oligosaccharides (FOS) or chicory anyway due to fructose malabsorption so they're off the menu.

Many years ago I did try the yakult, daily for several months. It seemed to help a little in settling nausea but it's full of sugar.

Hi Cort,
Where can I get the Part 1 interview with DR Logan. I had to go to a Gastro Doc the other day because of on going nausea. I only went because he was YOUNG so I knew he would not have the entrenched ideas of his forebears. I was right and he was sooo nice but could not help me as i cant take the drugs he needs to investigate. He admitted he knew nothing about CFS and was going to go away and learn about it. I would like to send this Dr Logan interview. Is there another one too I saw somewhere. I get so confused with what I have seen. with DR Merlier

I do a little freelance writing for a site called EduBook.com. They give me titles and I write articles for the titles.

Today I was writing an article for the title "The Health Benefits of Onions" and in doing a little research for it kept coming across "hydrogen sulfide" (wasn't that the big topic about the "big breakthrough" by Dr. Meirleir?) and then "fructo-oligosaccharides (FOS)".

Took a while for it to sort of sink in. Both terms looked familiar but at first I couldn't remember from where.

Then I remembered. It was from here.

No connection that I can see, between the titles EduBook sends me, and information on the forums. But ....

It basically sounds like a low carb hunter gatherer diet is what is best for CFS.

From what I've been hearing, Dr. Cheney is saying cut out all sweetners (except maybe glucose if not diabetic) Avoid most fruit, especially sweeter ones (blueberries, blackberries, cherries may be ok). I understand Cheney recommends goats milk kefir and mutaflor as probiotics. I am not his patient, so I cannot confirm this.

I've been diabetic, and put it into remission by eating low carb, so I'll continue to eat low carb.

I'm thinking of eating raw bison heart and maybe get some cell signaling factors, and RNA that way. I'm going to keep it frozen for two weeks before eating raw meat to kill germs. I know this may not be for everyone.

I was quite impressed with the Bifido initially, I had to stop using magnesium as it was all too much! After a week or so my gut became very unsettled and actually just using the diet meant I was far more stable and went back to the magnesium.

As I was having a good patch I thought I'd try Yakult, within the first day my right ear was twitching deep inside then it got warm around my ear and progressed to behind my eye under my jaw down my shoulder and throat, I feel nauseous, five days now, my stomach is painful and I feel like ****. Fresh pineapple is the only thing I have found to soothe the inflammation.

It feels as if the inflammation came directly up the vagus nerve, is it caused by the h2s, lactic acid (Yakult is a dairy product) or by the bacteria itself? I didn't have this feed back with bifido.

The post on co-cure that drew me to this thread made me think it was new material from Dr. Logan. Instead it was the post of one of us giving us valuable experience following suggestions/implications of what I and others think to be very important models of our version of ME.

I do wish that it would be made clear that updates to a thread whose name carries with it the authors of the model would not give that impression; but indicate it is one of the patient's on this forum updating and reporting.

But, I am getting truly worried and dissappointed that we don't get feedback from the original authors. Think of it as questions from the audience at a major lecture on one approach to ME. Without some guidance we become our own clinicians working with a model that the original authors probably now know more about OR could try to understand good and bad reactions to treatments suggested by their models, which also name treatments.

I don't have an answer and I don't have the energy to help devise one. But many of us don't even have ME knowledgeable doctors to ask. And those who do, given the complexity of the illness, don't always have clinical time with their docs to make sure they've read what we have and also then ask them to think about its implications for each of us. I've had some of the later and so, because I am super-reactive I am careful about introducing things till my doc has something to say. I did that with my probiotics, having read I think of Logan saying that some actually increases d-lactate and asked my doc if he felt culturelle gg would be an acceptable switch. He thought so and I went ahead.

Because so many things are happening (abscessed teeth and their need to be treated with zithromax, which has to be affecting the gut in some way) that it is hard to evaluate the culturelle though I am sticking with it .

I am more conservative than some because I've been sick so long, have had so many bad reactions, don't have a great caretaking system (to put it mildly), so that's my reaction. But I don't oppose being more into new things if you feel okay about it, especially with a mean disease like this one is.